ATI RN
ATI RN Custom Exams Set 5
1. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires immediate intervention?
- A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes.
- B. The nurse noted unilateral breast enlargement.
- C. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass.
- D. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.
Correct answer: D
Rationale: Choice D is the correct answer because a swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency. Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. This condition requires immediate intervention to prevent testicular damage. Choices A, B, and C do not present findings that suggest a surgical emergency requiring immediate intervention.
2. When measuring the leg circumference of a client with bipedal edema, what position is best to ensure accurate measurements?
- A. Dorsal recumbent
- B. Sitting
- C. Standing
- D. Supine
Correct answer: A
Rationale: When measuring the leg circumference of a client with bipedal edema, the best position to ensure accurate and consistent measurements is the dorsal recumbent position. This position allows the legs to be positioned comfortably, and the individual is lying on their back with legs extended, facilitating accurate measurement of the circumference without the influence of gravity. Sitting, standing, and supine positions may not provide optimal conditions for accurate leg circumference measurements, particularly in clients with bipedal edema where positioning and consistency are crucial. Sitting and standing positions may not allow for consistent leg positioning and could introduce errors due to the effects of gravity on the fluid distribution. The supine position, while similar to dorsal recumbent, may not be as comfortable for the client and could still be influenced by gravity when measuring leg circumference.
3. A client has been given instructions about ferrous sulfate. Which statement made by the client would indicate the client needs further education?
- A. I will take this medication on an empty stomach.
- B. I will take the morning dose 1 hour before breakfast.
- C. I will need to avoid taking this medication with coffee.
- D. I will take antacids if needed, 2 hours after I take ferrous sulfate.
Correct answer: A
Rationale: The correct answer is A. Ferrous sulfate should be taken on an empty stomach to improve absorption. Choice A is incorrect as taking the medication with a full glass of milk would impair iron absorption. Choices B, C, and D are all correct statements regarding the administration of ferrous sulfate. Choice B ensures proper timing before breakfast, choice C highlights avoiding coffee due to interference with iron absorption, and choice D correctly suggests taking antacids a few hours after ferrous sulfate to prevent potential interactions.
4. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?
- A. Secure a clean container
- B. Discard the container if the outside becomes dirty
- C. Rinse the client's mouth with Listerine before collection
- D. Tell the client that 4 tablespoons of sputum are needed
Correct answer: A
Rationale: The correct answer is to secure a clean container before sputum collection. This is essential to prevent contamination of the specimen, ensuring accurate test results and avoiding the introduction of external particles or bacteria. Choice B is incorrect because discarding the container if the outside becomes dirty is not necessary; the cleanliness of the inside is crucial. Choice C is incorrect as rinsing the client's mouth with Listerine before collection may introduce unwanted substances that can affect the test results. Choice D is incorrect as the amount of sputum required can vary depending on the test, and specifying a specific amount without medical guidance is not appropriate.
5. Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?
- A. Collect early in the morning, First voided specimen
- B. Do perineal care before specimen collection
- C. Collect 5 to 10 ml for urine
- D. Discard the first flow of the urine
Correct answer: A
Rationale: When collecting a mid-stream clean catch urine specimen for urine analysis, it is important to collect an adequate amount of urine for accurate testing. A volume of 30 to 60 ml is usually recommended for optimal results, so collecting only 5 to 10 ml would not provide enough urine for testing purposes. It is essential to follow proper collection techniques to ensure accurate and reliable test results.